Hello All,
Im looking for some assistance with this procedure. Im thinking this should be the unlisted code, 50949. Using the cpt 50947, as a comparison code, am I missing something? I could use a helping hand, as I am unsure if this comparison code would encompass both procedures. Any assistance is appreciated.
Thank you.
Shelly
ROBOTIC ASSISTED LAPAROSCOPIC URETERAL REIMPLANT WITH BOARI FLAP
A 16 French cystoscope was inserted transurethrally and pan cystourethroscopy revealed no masses or tumors. There was a adequate bladder capacity and the patient was filled to at least 500 cc to confirm an adequate bladder capacity for a Boari flap. The scope was removed and the patient was prepped in usual sterile fashion for robotic pelvic surgery. A Veress needle was inserted in Palmer's point and the abdomen was insufflated to 15 mmHg. An 18 French two-way Foley catheter was inserted transurethrally and 10 cc sterile water was placed in the balloon. A 8 mm robotic trocar was placed in the midline above the umbilicus and laparoscopy revealed no injury to viscus structures or vasculature. The Veress needle was removed and an 8 mm air seal port and an 8 mm robotic trocar placed in the right hemiabdomen. Two 8 mm robotic trocars were then placed in the left hemiabdomen under direct visualization. The patient was placed in Trendelenburg and the robot was docked with monopolar scissors in the right hand and fenestrated bipolar and ProGrasp in the left hand. There was a rind of inflamed peritoneum along the whole left hemiabdomen and the sigmoid colon was stuck to this. I identified the white line of Toldt up by the lower pole of Gerota's fascia and incised this and carried my dissection down into the pelvis medializing the sigmoid colon off of the pelvic sidewall. Once I had mobilized the colon medially indocyanine green was injected through the nephrostomy tube and I was able to identify the ureter with firefly on the robot. The ureter was circumferentially dissected and I continued my dissection distally until I encountered the space where the ureter entered the retroperitoneal space. A clip was applied to the ureter and then it was transected off of the space. The ureter was dissected more proximally until I had a good length. It was clear that the ureter was at or above the iliac vessels and so it was clear that a Boari flap would be required. A peritoneal incision was made just lateral to the right medial umbilical ligament and the space of Retzius was developed. A incision was made just medial to the left medial umbilical ligament and the space of Retzius was developed on the side. The median umbilical ligament was divided and traction was applied on the bladder as the space in the pelvis was developed further. Once the bladder was fully mobilized a portion of the pedicle to the bladder associated with the superior vesicle artery was divided using Weck clips. Catheter tip syringe was used to instill 400 cc into the urinary bladder and I was able to identify the contour of the bladder. A Boari flap was planned using a six 5 cm base of the flap at the dome. The flap was planned out using a marking pen. I ensured that the flap stayed at least 4 cm wide throughout its entire length and I selected a strip of bladder on the anterior bladder that was approximately 6 cm in length. The fat was cleared off of the urinary bladder and then I incised the detrusor and mucosa creating the flap.
The fat associated with the dome of the urinary bladder was secured to the peritoneum on the lateral wall to fix it to the ureter using a 2-0 V-Loc suture. The apex of the flap was secured to the fat associated with the dome of the bladder by passing it through the outer layers of the detrusor using 3-0 v loc suture. Once the bladder and flap were secured the ureter was reidentified and the Weck clip was cut off the end of the ureter and it was widely spatulated. Interrupted 4-0 Vicryl sutures were used to reapproximate the lateral and posterior portions of the ureter to the apex of the Boari flap. Once this was done I ran the bladder defect in a single layer using a simple running 2-0 v-loc suture. Once I was at the junction of the flap and the bladder proper a 6 French by 26 cm JJ ureteral stent was advanced up the ureter using a sensor wire. Once the wire was removed the distal portion of the stent was deployed in the urinary bladder. The flap was closed in a simple running fashion using 3-0 V-Loc suture up until it was at the level of the ureteral Boari flap anastomosis. The remainder of the anterior portion of the flap was completed in a simple interrupted fashion using 4-0 Vicryl suture. At this point the catheter was irrigated to confirm a watertight anastomosis. The perivesical fat by the dome of the bladder was used to create a wrap around the repair using 3-0 V-Loc suture. Tisseel was applied to the repair as well as the urinary bladder. A drain was placed in the left hemiabdomen and secured with a drain stitch. The robot was undocked and the patient was taken out of Trendelenburg. The fascia was closed in an interrupted fashion at each port site except for the drain site using 0 Vicryl suture in a UR 6 needle. Local anesthetic was injected of the wound margins and the skin was closed in a subcuticular fashion using 4-0 Monocryl suture. Skin glue was applied to the incisions and a drain site dressing was applied.
The nephrostomy tube was left clamped.
The patient was then recovered from anesthetic and returned to the recovery room in a stable condition.
Plan:
Patient should have his Foley catheter remain in place for 2 weeks before he obtains a cystogram. We will leave the nephrostomy tube in place until I am confident that there is not a urine leak.
Im looking for some assistance with this procedure. Im thinking this should be the unlisted code, 50949. Using the cpt 50947, as a comparison code, am I missing something? I could use a helping hand, as I am unsure if this comparison code would encompass both procedures. Any assistance is appreciated.
Thank you.
Shelly
ROBOTIC ASSISTED LAPAROSCOPIC URETERAL REIMPLANT WITH BOARI FLAP
A 16 French cystoscope was inserted transurethrally and pan cystourethroscopy revealed no masses or tumors. There was a adequate bladder capacity and the patient was filled to at least 500 cc to confirm an adequate bladder capacity for a Boari flap. The scope was removed and the patient was prepped in usual sterile fashion for robotic pelvic surgery. A Veress needle was inserted in Palmer's point and the abdomen was insufflated to 15 mmHg. An 18 French two-way Foley catheter was inserted transurethrally and 10 cc sterile water was placed in the balloon. A 8 mm robotic trocar was placed in the midline above the umbilicus and laparoscopy revealed no injury to viscus structures or vasculature. The Veress needle was removed and an 8 mm air seal port and an 8 mm robotic trocar placed in the right hemiabdomen. Two 8 mm robotic trocars were then placed in the left hemiabdomen under direct visualization. The patient was placed in Trendelenburg and the robot was docked with monopolar scissors in the right hand and fenestrated bipolar and ProGrasp in the left hand. There was a rind of inflamed peritoneum along the whole left hemiabdomen and the sigmoid colon was stuck to this. I identified the white line of Toldt up by the lower pole of Gerota's fascia and incised this and carried my dissection down into the pelvis medializing the sigmoid colon off of the pelvic sidewall. Once I had mobilized the colon medially indocyanine green was injected through the nephrostomy tube and I was able to identify the ureter with firefly on the robot. The ureter was circumferentially dissected and I continued my dissection distally until I encountered the space where the ureter entered the retroperitoneal space. A clip was applied to the ureter and then it was transected off of the space. The ureter was dissected more proximally until I had a good length. It was clear that the ureter was at or above the iliac vessels and so it was clear that a Boari flap would be required. A peritoneal incision was made just lateral to the right medial umbilical ligament and the space of Retzius was developed. A incision was made just medial to the left medial umbilical ligament and the space of Retzius was developed on the side. The median umbilical ligament was divided and traction was applied on the bladder as the space in the pelvis was developed further. Once the bladder was fully mobilized a portion of the pedicle to the bladder associated with the superior vesicle artery was divided using Weck clips. Catheter tip syringe was used to instill 400 cc into the urinary bladder and I was able to identify the contour of the bladder. A Boari flap was planned using a six 5 cm base of the flap at the dome. The flap was planned out using a marking pen. I ensured that the flap stayed at least 4 cm wide throughout its entire length and I selected a strip of bladder on the anterior bladder that was approximately 6 cm in length. The fat was cleared off of the urinary bladder and then I incised the detrusor and mucosa creating the flap.
The fat associated with the dome of the urinary bladder was secured to the peritoneum on the lateral wall to fix it to the ureter using a 2-0 V-Loc suture. The apex of the flap was secured to the fat associated with the dome of the bladder by passing it through the outer layers of the detrusor using 3-0 v loc suture. Once the bladder and flap were secured the ureter was reidentified and the Weck clip was cut off the end of the ureter and it was widely spatulated. Interrupted 4-0 Vicryl sutures were used to reapproximate the lateral and posterior portions of the ureter to the apex of the Boari flap. Once this was done I ran the bladder defect in a single layer using a simple running 2-0 v-loc suture. Once I was at the junction of the flap and the bladder proper a 6 French by 26 cm JJ ureteral stent was advanced up the ureter using a sensor wire. Once the wire was removed the distal portion of the stent was deployed in the urinary bladder. The flap was closed in a simple running fashion using 3-0 V-Loc suture up until it was at the level of the ureteral Boari flap anastomosis. The remainder of the anterior portion of the flap was completed in a simple interrupted fashion using 4-0 Vicryl suture. At this point the catheter was irrigated to confirm a watertight anastomosis. The perivesical fat by the dome of the bladder was used to create a wrap around the repair using 3-0 V-Loc suture. Tisseel was applied to the repair as well as the urinary bladder. A drain was placed in the left hemiabdomen and secured with a drain stitch. The robot was undocked and the patient was taken out of Trendelenburg. The fascia was closed in an interrupted fashion at each port site except for the drain site using 0 Vicryl suture in a UR 6 needle. Local anesthetic was injected of the wound margins and the skin was closed in a subcuticular fashion using 4-0 Monocryl suture. Skin glue was applied to the incisions and a drain site dressing was applied.
The nephrostomy tube was left clamped.
The patient was then recovered from anesthetic and returned to the recovery room in a stable condition.
Plan:
Patient should have his Foley catheter remain in place for 2 weeks before he obtains a cystogram. We will leave the nephrostomy tube in place until I am confident that there is not a urine leak.